Suffering in silence

Victims of selective mutism, speak in some places and don’t utter a sound elsewhere. An Israeli psychologist explains why.

Social anxiety that affects some seven children (or even young adults) out of 1,000, called selective mutism.
(photo credit: Courtesy)

Parents overwhelmed by their toddlers constantly talking and asking questions might enjoy some silence, but a young child who speaks only in certain settings – usually at home – while remaining wordless in others, such as in kindergarten and school, is frightening.

The condition of social anxiety that affects some seven children (or even young adults) out of 1,000, called selective mutism, can be successfully treated – especially if diagnosed early.

London-born psychologist Ruth Perednik, who lives outside Jerusalem and runs SM clinics, has personal experience with the child-anxiety disorder. Her son – one of five children with her husband Gustavo Perednik – was four years old when she stopped speaking outside the home.

She recalled that the child suddenly stopped speaking in kindergarten after the family had moved from Argentina to Israel. As very little was known then about the condition, he was “misdiagnosed and mistreated.”

Perednik collected information and decided to treat him herself at home and at school. Once she got interested in the subject, she recalled, “a steady flow of concerned parents contacted me and I began to help them, too.”

THE RARE condition is listed in the American Psychiatric Association’s Diagnostic & Statistical Manual of Mental Disorders. It is sometimes confused with autism or attention-deficit/ hyperactivity disorder, but it is very different. SM children are often moody, prone to sleep problems, prefer routine and are often regarded by others who don’t know about SM as rude – probably because they seem to be able to speak when they wish to. Many are above average in intelligence, creative, and sensitive to others’ thoughts and feelings.

Family stressors can play a role in SM. If a beloved grandmother who helped raise the child dies, writes Perednik, or if parents separate or divorce when a shy child with language problems begins kindergarten, SM could develop.

“Each child has a unique package of causes, which include genetic and environmental ones.”

Perednik writes that the condition is significantly more common in bilingual children and those who immigrate to a country speaking a different language from where they were born.

“Parents should pay attention to the language skills their child displays in his mother tongue in order to distinguish between difficulties inherent in bilingual language acquisition and objective language difficulties – which will usually be manifest in both languages.”

The psychologist graduated from University College London and the Institute of Education at the University of London in the1980s and studied educational psychology at the Hebrew University of Jerusalem in 2002.

Nine years later, she published an English-language, 256-page text on SM called The Selective Mutism Treatment Guide: Manuals for Parents, Teachers and Therapists, Still Waters Run Deep. Now, an expanded second edition has appeared under the Oaklands label, as well as a new Hebrew edition she wrote with Prof. Yoel Elitzur, head of the Hebrew University School of Education’s educational and child clinical psychology program and chairman of the Israel Council of Psychologists.

INVOLVED FOR 20 years in developing an effective treatment for SM, both through direct intervention by parents, teachers and therapists, and utilizing her online treatment intervention, she is considered a pioneer in the field. She will appear this week along with other psychologists dealing with SM, at a Jerusalem conference at devoted to the condition.

She developed an SM treatment method based on cognitive behavioral therapy techniques in the framework of her work in the Jerusalem psychological services in the Jerusalem Municipality.

Her treatment guide is extremely clear, easy to read and sometimes repetitive, because it includes three separate manuals written for parents, school or kindergarten staff and therapists. Each contains stepby- step lessons on how to help children with SM both at home, at kindergarten or school or elsewhere.

The Parents’ Manual includes sections about how SM can affect your child and family, how to speak to your child about it, treat SM, lower the child’s anxiety and work together with the school or kindergarten to help the child.

The Teacher’s Manual offers a description of SM and its possible causes, understanding the child with SM, how SM presents itself in school, an overview of how to treat SM and a variety of interventions and programs for teachers to implement in school.

The Therapist’s Manual provides sections on the definition and causes of SM, methods of assessment, levels of SM, planning therapy, cognitive- behavioral techniques for older children and teenagers, and detailed descriptions of the stages of therapy, including initial homebased therapy followed by schoolbased sessions.

She notes in the book that 90% of SM children suffer from social anxiety and 30% to 70% from some language or speech impairment. Other associated conditions could include shyness and hypersensitivity, oppositional behavior, stubbornness and perfectionism, neuro-developmental disorder or delay (often auditory processing delay) and learning disabilities. There is often a genetic component of shyness or a history of SM in one of the child’s parents or siblings. In addition, bilingualism, immigration and disconnectedness from the cultural milieu of the outside society are sometimes found in the families of children with SM. However, there is no link between intelligence and traumatic events that the child may have gone through and SM.

While many laymen think that being shy and introverted are the same thing, they are not, writes Perednik.

“An introvert enjoys time alone and gets emotionally drained after spending a lot of time with others.

A shy person doesn’t necessary want to be alone but is afraid to interact with others… While therapy can help the shy person, trying to encourage an introvert to be an outgoing introvert can be stressful and upsetting because it is attempting to alter a basic trait.”

Perfectionism also goes together with anxiety disorders, she continues.

“An anxious person may be concerned about impeccable functioning, as a result of which he or she is stressed about or refrains from doing a given task. One of the causes of SM is often the child’s fear as to whether he’ll be able to express himself adequately, whether his pronunciation is passable and whether he knows the answer.”

AS SM shows up in specific settings, it is best to treat the child in the place where the symptom is most pronounced. That is usually the kindergarten or school, but it can also occur in grandparents’ homes, doctors’ offices or shopping malls.

If the child speaks freely at home, it is recommended that a therapist first goes to the home to observe his behavior; the child also gets used to the therapist’s presence and can be naturally willing to speak in front of the stranger in the familiar setting.

The therapist can then go to the school for continued therapy while the teachers must be part of this “triumvirate” to report on the child’s functioning in class and begin their own interventions to encourage the child to speak.

Several times during the book, Perednik describes Rona, Dan and Leslie to give details of various patients of hers. Rona was a fiveyear- old redhead who looked fragile and stood silent in a swirl of activity and noise in her preschool class.

She never spoke in kindergarten – instead, she shut up and froze, speaking to no one and participating in nothing.

Dan was blond, five years old, and also silent in kindergarten, which he attended daily. He showed exceptional intelligence in his pictures, puzzles and worksheets and was liked by his peers, but he never spoke to them. At home, he was a chattering and singing child, making exquisite use of language, demanding his rightful place among his siblings and scolding his two cats.

Leslie was 14 years old, a tall girl with brown hair. She never spoke to anyone in kindergarten, elementary school or beyond. Leslie did, however speak to her (only) friend over the phone and sometimes invited her to her home after school. At home, she spoke fluently in both English and French. The parents of all three were very worried, thinking their children would never get over SM, but Perednik follows their progress through treatment for overcoming it.

Among the author’s cognitive behavioral techniques for getting the child to talk is recording their voices at home with a cellphone so they can be played for the therapist, teacher and other children in school. Talking photo albums are also effective. Parents may also come to school for talking/playing sessions with their child. Recorded WhatsApp messages that the child writes on what he ate for supper, what the weather is and so on can be sent to teachers and relatives.

Everything is aimed at lowering the child’s anxiety and increasing independence.

Perednik offers incredible detail in presenting therapy sessions. For example, one session, located in the school therapy room, was aimed at the child speaking to a therapist and a classmate, starting with games such as “You’re hot/cold,” voice recordings, throwing a ball and saying a name or object within a category, puppet shows, charades, 20 questions, Hangman and arts and crafts. In another session, in a relatively sheltered corner of the classroom, the child sat with the therapist, beginning with games that don’t require much talking and then moving on to games that do require talking and even conversations between them.

Incredibly, there are preteens and even teens who suffer from SM and have never spoken in school.

A whole chapter is devoted to their treatment.

“With an older child and certainly with teenagers, the cognitive elements of therapy become more prominent. As the child matures and becomes more introspective, the therapy has to be run along more egalitarian lines in which the child becomes an active partner working with the therapist to understand and treat his condition,” she suggests.

“Together with the therapist, the patient will consider and select steps that can be taken to enable speech, will share the responsibility in achieving these goals and will assess his behavior retrospectively.”

Relaxation techniques such as deep breathing, muscle relaxation, guided imagery and mindfulness are also recommended.

Finally, the appendix is full of checklists, apps that can help SM children and ideas for games involving throwing balls, playing boards, quizzes, physical movement and arts and crafts.

There is no clear mention of ways to prevent SM from developing; it may not be possible. One hopes that such things will be suggested and tested before the book’s third edition comes out.

Sites Of Interest

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